Predictive risk factors of acute kidney injury after on-pump coronary artery bypass grafting.

BACKGROUND: Acute kidney injury (AKI) is a common complication after coronary artery bypass grafting (CABG) and increases the risk of short and long-term morbidity and mortality. The aim of our study is to identify preoperative and intraoperative risk factors for development of AKI after primary isolated on-pump CABG. METHODS: In the retrospective study, 210 consecutive patients who underwent primary isolated on-pump CABG from January 2007 to March 2016 were included. The patients were divided into without AKI group (Group 1) and AKI group (Group 2) after operation. The s-Cr levels were recorded pre and postoperatively. The demographics, preoperative and postoperative data were collected from patient's medical profile and analyzed statistically. RESULTS: AKI developed in 40.5% of the patients (85 patients out of 210 patients). Age (Group 1; Group 2, 63.7±8.6; 67.2±8.2, P=0.004), body surface area (BSA) (Group 1; Group 2, 1.71±0.16; 1.64±0.16, P=0.003), body weight (Group 1; Group 2, 64.1±10.0; 60.7±10.2, P=0.017) were statistically significant for the development of AKI. However, preoperative hemoglobin, blood urea nitrogen (BUN), creatinine, estimated glomerular filtration rate (eGFR) and C-reactive protein (CRP) were not significant. As intraoperative factors, total pump time (TPT), aortic cross clamp time and transfusion were not significant. Female gender (OR 1.88; P=0.044), preoperative proteinuria (OR 2.711; P=0.011) and emergent operation (OR 2.641; P=0.035) were risk factors in univariate analysis. Preoperative proteinuria (OR 2.396; P=0.035) was only risk factor in multivariate analysis. CONCLUSIONS: Preoperative proteinuria was an independent predictor of postoperative AKI in patients undergoing primary isolated on-pump CABG. The accurate risk prediction of AKI after surgery can help clinicians manage more effectively in high-risk patients.

Rupture of right sinus of Valsalva aneurysm protruding into the pulmonary artery with aortic and pulmonary valve endocarditis.

Rupture of right sinus of Valsalva aneurysm (SVA) protruding into the pulmonary artery with aortic and pulmonary valve endocarditis is rare. A 42-year-old man was admitted with fever and dyspnea. He was diagnosed with right sinus of Valsalva rupture with ventricular septal defect (VSD) and vegetation on both aortic and pulmonary valves. Dual exposure technique was performed. The base of the aneurysm sac was closed off, and, together with the VSD, was covered by a Gore-Tex patch. Aortic and pulmonary valves were replaced with mechanical valves. After surgery, antibiotics were administered for 5 weeks, and patient was discharged without complications.

Late cardiac tamponade following Nuss procedure for pectus excavatum.

The Nuss procedure is a recently developed technique for correction of pectus excavatum. A 23-year-old female patient presented at our emergency department with clinical signs of cardiac tamponade, which required an emergency procedure. Sixteen months ago, she underwent the Nuss procedure with a single bar. Her preoperative Haller index was 5. We report on a case of delayed recurrent cardiac tamponade that occurred 16 and 18 months after the patient underwent the Nuss procedure; in this case, we treated the patient with pericardiocentesis the first time and performed pericardial window creation with bar removal the second time. She was discharged on day 10 in good condition and follow-up chest radiographs showed no fluid collection.

Mesoglycan attenuates VSMC proliferation through activation of AMP-activated protein kinase and mTOR.

BACKGROUND: Vascular smooth muscle cells (VSMC) proliferation contributes significantly to intimal thickening in atherosclerosis and restenosis diseases. Platelet derived growth factor (PDGF) has been implicated in VSMC proliferation though the activation of multiple growth-promoting signals. Mesoglycan, a natural glycosaminoglycans preparation, is reported to show vascular protective effect. However, the mechanisms by which mesoglycan inhibits proliferation of VSMC are not fully understood. Here, we investigated whether mesoglycan exert therapeutic effect via AMP-activated protein kinase (AMPK) and its underlying mechanism. METHODS: We cultured VSMC with increasing doses of mesoglycan. AMPK activation was measured by western blot analysis and cell proliferation was measured by flow cytometry. RESULTS: Mesoglycan dose- and time- dependently increased the phosphorylation of AMPK (Thr(172)) and its upstream target, LKB1 (Ser(428)) and its downstream, ACC (Ser(79)) in VSMCs. Mesoglycan also blocked the PDGF-stimulated cell cycle progression through the G0/G1 arrest. AMPK DNα1, AMPK DNα2 or AMPK siRNA reduced the mesoglycan-mediated inhibition of VSMC proliferation. AMPK signaling activated by mesoglycan regulates mTOR phosphorylation which closely related to cell proliferation. CONCLUSION: These data suggest that mesoglycan-induced AMPK activation suppress the VSMC proliferation via mTOR-dependent mechanism and mesoglycan may have beneficial effects on vascular proliferative disorders such as atherosclerosis.

Electrocautery-Ignited Surgical Field Fire Caused by a High Oxygen Level during Tracheostomy.

Tracheostomy is a relatively common surgical procedure that is performed easily in an operating room or intensive care unit. Open tracheostomy is needed in patients requiring prolonged ventilation when percutaneous tracheostomy is inappropriate. Sometimes, it is difficult to achieve bleeding control in the peritracheal soft tissue, and in such cases, we usually use diathermy. However, the possibility of an electrocautery-ignited surgical field fire can be overlooked during the procedure. This case report serves as a reminder that the risk of a surgical field fire during tracheostomy is real, particularly in patients requiring high-oxygen therapy.

The rupture of atrioventricular groove after mitral valve replacement in an elderly patient.

Rupture of the left ventricle after mitral valve replacement, although infrequent, may be a highly lethal complication. This report describes the early diagnosis and successful repair of rupture of atrioventricular groove in an elderly patient who underwent mitral valve replacement.

Mid-term results in patients having tricuspidization of the quadricuspid aortic valve.

BACKGROUND: Quadricuspid aortic valve (QAV) is a rare congenital anomaly. We investigate the mid-term results of aortic valve reconstruction by tricuspidization in patients with QAV. METHODS: We analyzed the outcome of eight consecutive patients who underwent aortic valve reconstruction surgery (AVRS) with pericardial leaflets with symptomatic quadricuspid aortic valve (QAV) disease between December 2007 and May 2012. AVRS consists of leaflet reconstruction and fixation of the sino-tubular junction in order to maintain coaptation of the new valve. RESULTS: Six males and two females were included; ages ranged from 19 to 63 years (mean age, 51 years). According to Hurwitz and Roberts's classification, three patients had type A, three patients had type B, one patient had type C, and one patient had type E. All patients had significant aortic regurgitation (AR): moderate in three patients, moderate to severe in one patient, and severe in four patients. Concomitant ascending aorta wrapping with an artificial vascular graft was performed in one case. There was no occurrence of mortality during the follow-up period (42.4 ± 18.0 months). No redo-operation was required. The NYHA functional class showed improvement from 2.1 ± 0.2 to 1.1 ± 0.2 (p= 0.008). The latest echocardiograms showed AR absent or trivial in seven patients, and mild in one patient. The aortic valve orifice area index (AVAI) was 1.03 ± 0.49 cm2/m2. Compared with preoperative echocardiograms, the left ventricular (LV) ejection fraction showed improvement from 57.6 ± 17.0 to 63.7 ± 13.2% (p=0.036); the end-diastolic and end-systolic LV dimensions showed a significant decrease, from 63.5 ± 9.6 to 49.5 ± 3.1 mm (p=0.012) and 43.6 ± 11.8 to 32.1 ± 5.4 mm (p=0.012), respectively. CONCLUSION: In patients with QAV, AVRS with tricuspidization showed satisfactory early and mid-term results. Long-term follow-up will be necessary in order to study the durability of AVRS; however, it can be considered as a potential standard procedure.

Aortic valve reconstruction with leaflet replacement and sinotubular junction fixation: early and midterm results.

BACKGROUND: Aortic valve reconstruction surgery (AVRS), consisting of aortic leaflet reconstruction with tailored pericardial patches and fixation of the sinotubular junction with properly sized fabric rings, is performed for the treatment of aortic valve diseases. The early and midterm outcomes of AVRS were analyzed. METHODS: Between December 2007 and December 2012, 262 patients with isolated aortic valve disease underwent AVRS in one center. Clinical outcomes, effective orifice area, mean gradients, and left ventricular mass index were evaluated yearly. RESULTS: Mean follow-up duration was 36.0±17.1 months and was complete in 100% of surviving patients. There was no hospital mortality, but there were 3 late deaths (1.1% late mortality). Seven patients (2.7%) required reoperation: 5 because of endocarditis and 2 because of suture disruption of the leaflets. Ten patients (3.8%) experienced neurologic events. Aortic valve regurgitation was absent or trivial in 226 patients (87.3%) and mild in 29 (11.2%), mild to moderate in 3 (1.2%), and moderate to severe in 1 (0.4%). The mean valve gradient and valve orifice index were 10.6±5.3 mm Hg and 1.3±0.4 cm2/m2, respectively. CONCLUSIONS: The data from the first 5 years after AVRS reveal good clinical and hemodynamic outcomes, suggesting that AVRS is a new alternative technique to the practice of replacement with stented bioprostheses and mechanical prostheses. However, whether the reconstructed aortic valve represents a truly long-term valve remains to be demonstrated.

Acute thrombosis of bioprosthetic mitral valve.

We report a case of acute thrombosis of bioprosthetic mitral valve in a 59 year-old Korean female, who underwent a mitral valve replacement with a 25 mm Carpentier - Edwards PERIMOUNT Plus bioprosthesis (Edwards Lifesciences, Inc.; Irvine, CA, USA) and a mini-Maze procedure for correction of mitral stenosis (MS) and atrial fibrillation (AF). On the 10th postoperative day, the patient began to complain of increasing dyspnea and general malaise. Her symptoms worsened and developed into pulmonary edema. Echocardiography revealed a mean diastolic pressure gradient (MDPG) of 10 mmHg across the mitral valve and pressure-half time (PHT) of 166 msec. Due to progressive decompensated heart failure, the patient underwent a repeat sternotomy to replace the bioprosthetic mitral valve. Intraoperatively, we found a thrombosis around the bioprosthetic mitral valve. We excised the bioprosthetic mitral valve and replaced it with a 27 mm ATS mechanical valve (ATS medical, Inc.; Minneapolis, MN, USA). We experienced a rare case that required an early reoperation for a thrombosis of the bioprosthetic valve.

High glucose induces connective tissue growth factor expression and extracellular matrix accumulation in rat aorta vascular smooth muscle cells via extracellular signal-regulated kinase 1/2.

Connective tissue growth factor (CTGF) is a potent pro-fibrotic factor, which is implicated in fibrosis through extracellular matrix (ECM) induction in diabetic cardiovascular complications. It is an important downstream mediator in the fibrotic action of transforming growth factor ß (TGFß) and is potentially induced by hyperglycemia in human vascular smooth muscle cells (VSMCs). Therefore, the goal of this study is to identify the signaling pathways of CTGF effects on ECM accumulation and cell proliferation in VSMCs under hyperglycemia. We found that high glucose stimulated the levels of CTGF mRNA and protein and followed by VSMC proliferation and ECM components accumulation such as collagen type 1, collagen type 3 and fibronectin. By depleting endogenous CTGF we showed that CTGF is indispensable for the cell proliferation and ECM components accumulation in high glucose-stimulated VSMCs. In addition, pretreatment with the MEK1/2 specific inhibitors, PD98059 or U0126 potently inhibited the CTGF production and ECM components accumulation in high glucose-stimulated VSMCs. Furthermore, knockdown with ERK1/2 MAPK siRNA resulted in significantly down regulated of CTGF production, ECM components accumulation and cell proliferation in high glucose-stimulated VSMCs. Finally, ERK1/2 signaling regulated Egr-1 protein expression and treatment with recombinant CTGF reversed the Egr-1 expression in high glucose-induced VSMCs. It is conceivable that ERK1/2 MAPK signaling pathway plays an important role in regulating CTGF expression and suggests that blockade of CTGF through ERK1/2 MAPK signaling may be beneficial for therapeutic target of diabetic cardiovascular complication such as atherosclerosis.

Surgery for subclavian arteriovenous fistula with ruptured pseudoaneurysm using total circulatory arrest.

Subclavian arteriovenous (AV) fistula is an uncommon disease and rarely occurs secondary to injury. We herein report a case of a ruptured pseudoaneurysm with a subclavian AV fistula caused by clavicle fixation. In cases of a large ruptured pseudoaneurysm with a massive surrounding hematoma, bleeding control and vessel repair is very difficult. For treatment of this case, we decided that median sternotomy and cardiopulmonary bypass with total circulatory arrest would be a good alternative to surgery.

Insulin Like Growth Factor Binding Protein-5 Regulates Excessive Vascular Smooth Muscle Cell Proliferation in Spontaneously Hypertensive Rats via ERK 1/2 Phosphorylation.

Insulin-like growth factor binding proteins (IGFBPs) are important components of insulin growth factor (IGF) signaling pathways. One of the binding proteins, IGFBP-5, enhances the actions of IGF-1, which include the enhanced proliferation of smooth muscle cells. In the present study, we examined the expression and the biological effects of IGFBP-5 in vascular smooth muscle cells (VSMCs) from spontaneously hypertensive rats (SHR) and Wistar Kyoto rats (WKY). The levels of IGFBP-5 mRNA and protein were found to be higher in the VSMC from SHR than in those from WKY. Treatment with recombinant IGFBP-5-stimulated VSMC proliferation in WKY to the levels observed in SHR. In the VSMCs of WKY, incubation with angiotensin (Ang) II or IGF-1 dose dependently increased IGFBP-5 protein levels. Transfection with IGFBP-5 siRNA reduced VSMC proliferation in SHR to the levels exhibited in WKY. In addition, recombinant IGFBP-5 significantly up-regulated ERK1/2 phosphorylation in the VSMCs of WKY as much as those of SHR. Concurrent treatment with the MEK1/2 inhibitors, PD98059 or U0126 completely inhibited recombinant IGFBP-5-induced VSMC proliferation in WKY, while concurrent treatment with the phosphatidylinositol-3 kinase inhibitor, LY294002, had no effect. Furthermore, knockdown with IGFBP-5 siRNA inhibited ERK1/2 phosphorylation in VSMC of SHR. These results suggest that IGFBP-5 plays a role in the regulation of VSMC proliferation via ERK1/2 MAPK signaling in hypertensive rats.

Pulmonary artery intimal sarcoma: poor 18F-fluorodeoxyglucose uptake in positron emission computed tomography.

Intimal sarcoma of the pulmonary artery is a rare malignant tumor that may be misdiagnosed as chronic pulmonary thromboembolism, even if various imaging techniques are used. We report a case of a 58-year-old man with pulmonary artery intimal sarcoma.18F-fleuorodeoxyglucose (FDG) uptake was poor in the mass of the pulmonary artery, and no other hypermetabolic lesions were noted elsewhere. Our presumptive diagnosis was a massive mural thrombus and a concomitant chronic thromboembolism. Intravenous heparin and recombinant human tissue-type plasminogen activator was subsequently administered. However, the patient needed an emergency operation for sudden aggravation of the vital signs, and the tissue diagnosis was intimal sarcoma with poor clinical outcomes.

IGFBP5 mediates high glucose-induced cardiac fibroblast activation.

This study examined whether IGF-binding protein 5 (IGFBP5) is involved in the high glucose-induced deteriorating effects in cardiac cells. Cardiac fibroblasts and cardiomyocytes were isolated from the hearts of 1- to 3-day-old Sprague Dawley rats. Treatment of fibroblasts with 25 mM glucose increased the number of cells and the mRNA levels of collagen III, matrix metalloproteinase 2 (MMP2), and MMP9. High glucose increased ERK1/2 activity, and the ERK1/2 inhibitor PD98059 suppressed high glucose-mediated fibroblast proliferation and increased collagen III mRNA levels. Whereas high glucose increased both mRNA and protein levels of IGFBP5 in fibroblasts, high glucose did not affect IGFBP5 protein levels in cardiomyocytes. The high glucose-induced increase in IGFBP5 protein levels was inhibited by PD98059 in fibroblasts. While recombinant IGFBP5 increased ERK phosphorylation, cell proliferation, and the mRNA levels of collagen III, MMP2, and MMP9 in fibroblasts, IGFBP5 increased c-Jun N-terminal kinase phosphorylation and induced apoptosis in cardiomyocytes. The knockdown of IGFBP5 inhibited high glucose-induced cell proliferation and collagen III mRNA levels in fibroblasts. Although high glucose increased IGF1 levels, IGF1 did not increase IGFBP5 levels in fibroblasts. The hearts of Otsuka Long-Evans Tokushima Fatty rats and the cardiac fibroblasts of streptozotocin-induced diabetic rats showed increased IGFBP5 expression. These results suggest that IGFBP5 mediates high glucose-induced profibrotic effects in cardiac fibroblasts.

Multiple paravalvular leak 17 years after a second mitral valve replacement.

Paravalvular leak (PVL) after prosthetic valve implantation is a significant complication and it usually occurs early in the postoperative period. We report a case of multiple PVL 17 years after the second mitral valve replacement without evidence of infection. The valve sutures were neither cut nor loosened. None of the sewing cuff of the mitral valve was covered with fibrous tissue. The sewing cuff was floated over the native annulus and large and multiple leakage was developed. The valve was easily removed and replaced with a new mechanical prosthesis.

Acute post-cardiopulmonary bypass left atrial thrombosis after mitral valvuloplasty and left atrial thrombectomy.

A patient with mitral stenosis and multiple left atrial thrombi underwent valvuloplasty and thrombectomy. While closing the sternum after completing the cardiopulmonary bypass, a new left atrial thrombus was detected by transesophageal echocardiography. We used heparin for the prevention of new thrombus formation and closed the wound after meticulous bleeding control. Three months later, there was no residual thrombus in the left atrium according to the echocardiographic study.

Acute Type II Aortic Dissection with Severe Aortic Regurgitation and Chronic Descending Aortic Dissection in Pregnant Patient with Marfan Syndrome.

Aortic dilatation and dissection are severe complications during pregnancy that can be fatal to both the mother and the fetus. The risks of these complications are especially high in pregnant patients with Marfan syndrome; however, incidents of descending aortic dissection are very rare. This case report involves a successful Bentall procedure for and recovery from a rare aortic dissection in a pregnant Marfan patient who developed acute type II aortic dissection with severe aortic regurgitation and chronic descending aortic dissection immediately after Cesarean section. Regular follow-up will be needed to monitor the descending aortic dissection.